Case Based Reviews in Pediatric Pulmonology Rakesh Lodha, Kana Ram Jat, Jhuma Sankar, Sushil K Kabra
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1Disorders of Upper Respiratory Tract2

Common ColdCHAPTER 1

Deo K Jha
Q. What may be diagnostic possibilities here?
Diagnostic possibilities include common cold, influenza or swine flu, bronchiolitis, pneumonia, or allergic rhinitis. Let us explore all possibilities: allergic rhinitis is rare in this age group. It may be associated with other allergic conditions like allergic dermatitis, allergic conjunctivitis, or allergic airways disease and history should be of long time. There may be family history of atopy which we should ask the parents. In pneumonia, there should be high fever, with toxic look of baby with tachypnea which is a constant feature of pneumonia with or without chest retraction. On chest auscultation, one should get the finding of reduced intensity of breath sound or bronchial breath sound over affected area. There may be deep inspiratory crackles on auscultation. In bronchiolitis, there may be low- to high-grade fever, but if it is high grade at onset, it usually wanes over next 2–3 days. Child does not look toxic and respiratory distress may or may not be present. On auscultation of chest, there will be wheezes with or without early inspiratory crackles. In influenza or swine flu, the presentation will be more severe with continuous high-grade fever, vomiting, and loose motion and it is very difficult to feed the child. There may be history of proven swine flu in the family or in the society.
Looking on the case above, these possibilities are remote. So, it may be a case of our first possibility that is common cold.
Q. What is epidemiology of common cold?
The most common infective disease of human being is common cold. It is a great burden on society in terms of sufferings by children and number of working days lost by parents for caring of their children, despite enormous advancement in medical science in terms of preventive, diagnostic, and treatment facilities. It affects more infants and children than adults. Children <6 years of age may have one episode of common cold every month without any cause of concern. It is a self-limiting viral infection of upper respiratory tract. Symptoms 4 vary depending upon the type of virus responsible for a particular infection. More than 50% of infections in children are caused by Rhinoviruses which have >100 serotypes. Other less common viruses responsible are adenovirus, respiratory syncytial virus (RSV), human metapneumovirus, influenza virus, and parainfluenza virus.
Seasonal patterns
Common cold is not caused by exposure to cold air or cold environment. It can occur in any season but occurs more commonly during fall and spring season irrespective of geographical locations. Any virus can infect children in any season, but the highest prevalence of some of the viruses has been seen in different seasons of the year as follows: Rhinovirus—early fall and late spring like in July–August and March–April; parainfluenza virus—late fall and late spring like in September–October and March–April; and RSV and influenza virus—mid winter throughout spring up to late spring like from December–April.
Mode of transmission
It is transmitted from person to person. When a child or adult suffering from common cold rubs his or her nose and then touches the hands of other person and then he or she touches his or her eyes or nose, the virus enters into that person because the virus remains alive on hands for about 2 hours. Common cold virus remains alive for about 24 hours on surfaces of toys, door handles, and table–tops and it can infect other person during this period. Common cold virus, particularly Rhinovirus, does not usually get transmitted by droplets but influenza virus can. Common cold is not usually transmitted by saliva.
Mannose-binding lectin deficiency with impaired innate immunity in children makes them excessive susceptible to common cold. Asthmatic bronchial cells produce less b-interferon, which makes asthmatic children more susceptible to rhinovirus infection. There is variation in severity of common cold symptoms due to the polymorphism of cytokine genes, suggestive of genetic predisposition.
Viruses induce inflammation of nasal mucosa with or without mucosal lining of sinuses without damaging the epithelium. Kinin and cytokines are secreted by the epithelial lining after contact with viruses. Interleukin-8, which is secreted, attracts polymorphonuclear inflammatory cells. Inflammatory cells may block opening of sinuses or Eustachian tube with its complications. Prostsglandin and kinin which are released locally, cause vasodilatation; increased vascular permeability, and excessive secretion from exocrine glands. Stimulation of parasympathetic nerve endings along with these is responsible for symptoms.
Q. What are common clinical features of common cold?
The most common complaint in children suffering from common cold is nasal congestion which starts after 24–48 hours of exposures. Incubation period is 12–72 hours, but symptom has been noticed as early as 2 hours after contact. Fever of low grade 38°C or 100.4°F is common in first 3 days of illness. Nasal discharge may be watery, yellowish, or green. Other features are sore throat, cough, irritability, decrease in appetite with difficulty to feed the child, and 5difficulty in getting sleep which is disturbing for parents also. There may be watering from eyes with redness secondary to rubbing of eyes. There may be mild headache and loss of taste and loss of smell during the period. There may be hoarseness of voice in some children. There may be malaise with loss of interest in play and study.
Nasal mucosa may be swollen and edematous, and there may be nontender enlargement of cervical lymph nodes. Symptoms usually last for 7–10 days but may be prolonged to 14 days in some cases. Some times a second common cold virus infects the child during this prolonged period which gives confusion to physician that the first one is prolonging, but it should not be a cause of concern unless any sign of secondary bacterial infection is there.
Q. How we can diagnose common cold? What is the role of various investigations?
Diagnosis is primarily clinical. There is no role of investigations like hemogram, chest X-ray, throat swab and X-ray paranasal sinuses. There is no benefit of isolation of virus as antiviral agents are available for only few viruses.
Q. When one should worry in common cold and what complications may be there?
The following features may be the cause of concern in a child with common coldfever of 100.4°F in infants from birth up to 12 weeks of age; fever lasting >1 day (24 hours) in a child <2 years of age, fever lasting >2 days (48 hours) in a child >2 years of age, fever of 104°F and being repeated to such an extent in a child of any age, fever >101°F lasting for >3 days in any age of child, excessive sleepiness, pain abdomen, vomiting, impaired consciousness, very poor or no oral intake, severe headache, neck stiffness, ear pain, persistent cry, difficulty in breathing, and persistent cough.
Common colds are usually self-limiting but sometimes get complicated by the following:
(1) acute otitis media, is the commonest complication; (2) asthma: children who are predisposed for asthma may get first episode of wheezing during common cold or the common cold may exacerbate the pre-existing asthma; (3) sinusitis: it should be suspected if the symptoms of common cold are prolonged for >10–14 days or if there is worsening of symptoms after initial improvement or the symptoms start with high-grade fever which prolong for >3 days; (4) secondary bacterial infection like bacterial tonsillopharyngitis as seen in case 3: and (5) pneumonia: child may be complicated by viral as well as secondary bacterial pneumonia which should be suspected if there is tachypnea, cough and high-grade fever.
Q. How to manage a child with common cold?
Market is flooded of formulations for common cold remedy with antihistaminics, antitussive cough syrups, decongestants, and expectorants. These are being used by parents very frequently. But no randomized controlled trials have shown benefit with these medications in children under the age of 6 years. Moreover, The Food and Drug Administration (FDA) has banned these medications for use in children below 2 years of age and further studies have indicated no benefit of these below 6 years of age. It has been seen in our experience that it gives only psychological benefits to the parents, so the use of these medications should be discouraged.
6Symptomatic treatment in the form of paracetamol for fever and discomfort due to malaise should be given in the dose of 10–15 mg/kg body weight, which can be repeated 4–6 hourly if needed. Ibuprofen can be used in infants above 6 months of age in the dose of 7.5–10 mg/kg body weight, repeated every 6–8 hours if needed. Aspirin should not be used in children below 18 years of age due to fear of Reye syndrome. Symptoms due to nasal blockage should be taken care by instilling saline nasal drop into each nostril several times a day or it can be sprayed into the nostrils and secretions sucked out by bulb syringe. Nighttime cough may be treated by giving honey to children above 12 months of age. Symptoms of rhinorrhea may be decreased by 25–35% by giving first generation antihistaminics and anticholinergics. Child should be encouraged to take adequate fluid without forcing to take extra water intake.
Second generation nonsedative antihistaminics are not effective. There is no role of any antibiotics and its use may increase the resistance of antibiotics in society. Moreover, excessive irrational use of antibiotics to treat viral infections in children below 1 year of age may predispose the child to develop asthma after 6 years of age. Steam (warm humidified air) inhalation is not found to be effective for common cold and there is risk of burn in children and should not be used. Other preparations like zinc, vitamin C, and herbal product like Echinacea have no proven role, although being used with variable results.
Q. How common cold can be prevented? Is vaccine effective for common cold?
By the time we notice the symptoms of common cold in children, it might have infected several children because it is most infectious in initial 2–4 days. The most effective way of limiting the spread is by hand-washing for 15–30 seconds with soap water, without the need of any soap containing antibacterial. If water and sink is not available, hand rub containing alcohol as disinfectant can be used, it should be spread over both surfaces of hands until it dries. It is practically impossible to keep the infected person away from contact but they should be advised to cough or sneeze into tissues and wash hands frequently.
Vaccines to prevent common cold are not possible, seeing the large variation in antigenic type of virus.
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